Provider Demographics
NPI:1275897076
Name:GAVIRNENI, MADHAVI (MD)
Entity Type:Individual
Prefix:DR
First Name:MADHAVI
Middle Name:
Last Name:GAVIRNENI
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 699
Mailing Address - Street 2:
Mailing Address - City:MOUNTAIN HOME
Mailing Address - State:TN
Mailing Address - Zip Code:37684-0699
Mailing Address - Country:US
Mailing Address - Phone:423-433-6039
Mailing Address - Fax:423-433-6060
Practice Address - Street 1:2332 BEVERLY HILLS DR
Practice Address - Street 2:
Practice Address - City:FT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76114-1756
Practice Address - Country:US
Practice Address - Phone:817-378-0855
Practice Address - Fax:817-378-0861
Is Sole Proprietor?:No
Enumeration Date:2012-06-27
Last Update Date:2019-02-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN53236208000000X
TXQ8890208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3714470OtherGROUP MEDICARE